An intensely itchy rash on the abdomen - Clinical Advisor

An intensely itchy rash on the abdomen

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A 72-year-old man presents to the clinic with an intensely itchy rash on his abdomen and chest that appeared 2 months prior. He denies starting any new medications prior to the onset of the eruption and any systemic symptoms. Although he traveled and stayed in hotels recently, he reports that his wife does not exhibit any similar symptoms. Physical examination reveals numerous discrete papules, crusted papules, and papulovesicles on the chest, abdomen, and mid-back. His upper and lower extremities, face, and groin are unaffected. 

 

Grover disease (GD), also known as transient acantholytic dermatosis, is a common yet challenging condition that occurs predominantly in middle- to older-aged men. Dr Ralph W. Grover first characterized it in the 1970s. Both the names Grover disease and transient acantholytic dermatosis...

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Grover disease (GD), also known as transient acantholytic dermatosis, is a common yet challenging condition that occurs predominantly in middle- to older-aged men. Dr Ralph W. Grover first characterized it in the 1970s. Both the names Grover disease and transient acantholytic dermatosis are misnomers, as this condition not a worrisome disease, nor is it typically very transient.

GD occurs commonly in middle-aged patients, with an average age of onset at 64 years.1 It affects men almost twice as often as women. In addition, one study found that this condition is biopsied and diagnosed more frequently in the winter.1 GD may last a few months and then resolve spontaneously or it may persist for many years, with the rash waxing and waning.

The origin and pathogenesis of GD is unknown. It is nonfamilial and not immune mediated. Several factors appear to be related to disease onset and flare. These include ultraviolet and ionizing radiation, sweating, heat, and xerosis.2 Interestingly, GD often appears or flares during periods of prolonged bedrest and hospitalization.3 GD also appears to be associated with eczema and allergic contact dermatitis.2

GD presents with discrete, usually monomorphic papules, papulovesicles, crusts, and keratotic erosions, ranging in size from 1 to 3 mm. Lesions may resolve with postinflammatory hyper- or hypopigmentation. Common areas of involvement include the abdomen, chest, and back. The face, groin, palms, and soles are typically spared.

Pruritus is usually present, and often the extreme intensity of the itch may seem incompatible with the rash severity.

The differential diagnoses of GD are vast; therefore, conclusive diagnosis of GD is challenging for many clinicians. Similar-appearing conditions to consider include drug eruptions, scabies, folliculitis, miliaria, insect bites, and vesicular disorders such as bullous pemphigoid and pemphigus vulgaris.

Histopathlogically, GD is an acantholytic process with disruption of the intercellular connections between epidermal keratinocytes. Dyskeratosis may or may not be present. In addition, hyperkeratosis and parakeratosis may be seen. In the setting of a background of eczematous skin, a spongiotic pattern of inflammation will be present. The histopathologic differential diagnoses include Darier disease, Hailey- Hailey disease, pemphigus foliaceus, and pemphigus vulgaris. Therefore, clinical correlation is required to reach the correct diagnosis. In questionable cases, direct immunofluorescence testing is helpful to rule out autoimmune vesicular disorders.

Treatment typically includes use of topical cortisone creams to decrease inflammation and itching. Triamcinolone 0.1% cream can be applied twice daily as needed to the trunk. Corticosteroid use is limited to short-term application given the risk of side effects with long-term use.

Emollient use should be encouraged to optimize skin integrity. Over-the-counter creams containing menthol or pramoxine often provide temporary, soothing relief. Oral antihistamines may aid in pruritus relief. Nonsedating antihistamines may be used during the day, whereas nonsedating antihistamines, such as hydroxyzine and diphenhydramine, should be reserved for nighttime use.

In addition, behavior modifications may improve the condition; patients should avoid situations that lead to overheating and sweating, such as intense exercise and sunbathing. Wearing cool, loose clothing is beneficial.

For stubborn cases, other reported treatment options include the tumor necrosis factor antagonist etanercept,4 oral isotretinoin,5 and psoralen and ultraviolet A radiation photochemotherapy.6

For the patient above, a punch biopsy sample sent for histopathologic examination confirmed the diagnosis of GD. The patient was prescribed triamcinolone 0.1% cream to be used up to a maximum of three times daily as needed for itching. In addition, he was advised to wear loose clothing and avoid situations in which overheating may occur. Three months later, the patient reported the condition was still present but was no longer very bothersome.

Esther Stern, NP, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J. 

References

  1. Scheinfeld N, Mones J. Seasonal variation of transient acantholytic dyskeratosis (Grover’s disease). J Am Acad Dermatol. 2006;55:263-268.
  2. Parsons JM. Transient acantholytic dermatosis (Grover’s disease): a global perspective. J Am Acad Dermatol. 1996;35(5 Pt 1):653-666.
  3. James WD, Berger TG, Elston DM, eds. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, PA: Saunders-Elsevier; 2011.
  4. Norman R. Use of etanercept in treating pruritus and preventing new lesions in Grover’s disease: a case report. J Am Acad Dermatol. 2007;56(suppl 2):AB53.
  5. Helfman RJ. Grover’s disease treated with isotretinoin. Report of four cases. J Am Acad Dermatol. 1985;12:981-984.
  6. Lebwohl MG, Heymann WR, Berth-Jones J, Coulson I. Treatment of Skin Disease. Comprehensive Therapeutic Strategies. 3rd ed. Philadelphia, PA; Elsevier Saunders: 2010.

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